Payment: Payment for services is due at the time of service. Accepted methods of payment include cash, check, credit, debit and HSA card. There will be a $25 service fee on all returned checks. Any patient whose account is past due is subject to late fees and suspension of treatment until the bill is paid. In the event that your account goes to collections, there will be a 20% collection fee added to your balance.
Insurance: I do not accept insurance and would be considered an out-of-network provider. However, payment for services will be due in full at the time of service. You may then submit the paperwork and request that the insurance company make the payment directly to you.
45 minute appointment $300
30 minute appointment $250
15 minute appointment $175
5 minute appointment, text, and email follow up $125
Reports, Consultations and Other Clerical Matters: Any reports, professional consultations, or clerical tasks involving time beyond that of the regular scheduled session will be billed at the rate of $400 per hour.
Phone Calls: Phone calls for clinical matters will be billed at a rate of $400 per hour.
Cancellation Policies: Please cancel appointments with at least 48 business hours notice, e.g., for a Monday appointment, you need to cancel by Thursday at the same time of the appointment and for a Tuesday appointment, you need to cancel by Friday at the same time of the appointment. Cancellations with fewer than 48 business hours notice or no-shows will result in a fee equivalent to the full normal visit rate.
Confidentiality: Information shared in psychotherapy is confidential and is not discussed with anyone without a release form signed by you. However, there are legal limits to confidentiality. If indications of child abuse or planned bodily harm to oneself or to others come to light in the course of treatment, I am legally bound to report these to the appropriate authorities.
Patient Rights: You are entitled to the highest quality of psychiatric care available. Psychotherapy is a joint undertaking, with rights and responsibilities shared by both of us. I am always interested in responding to whatever questions, concerns, or feelings you may have regarding your care.
Over time, these office policies may be adjusted. I will inform you openly regarding all changes.
Release and Statement of Responsibility
1. I have read and understand the above information.
2. I agree to the terms of the office payment and cancellation policies.
Name: ___________________________________ Date: _____________